Abstract

The impact of environmental features of residences on adaptive behavior, community integration, and health of adults with mental retardation over an 8-year period was examined. Environmental features included residence type, size, choice-making opportunities, physical attractiveness, and family involvement. We assessed 186 residents who initially lived in nursing homes. At the 8-year follow-up, 133 had moved to community-based residential settings. Findings indicated that residents who moved to community settings had higher levels of adaptive behavior and community integration than residents who remained in nursing homes. A more attractive physical environment and greater opportunity for choice-making were associated with higher levels of adaptive behavior at follow-up. Greater opportunity to make choices and family involvement were associated with higher levels of community integration.

Editor in charge: Steven J. Taylor

Many adults with mental retardation live outside the family home in a variety of residential settings (Fujiura, 1998). Over the last decade, researchers have demonstrated greater interest in how different environmental aspects of residential settings influence the well-being of persons with mental retardation. Most of this research has focused on how differences in the type and size of residential settings influence outcomes among residents with mental retardation. Only recently have researchers begun to look more closely at specific aspects of the environment beyond size and type that influence resident outcomes. We planned the current study to further explore how aspects of the environment influence resident outcomes using a long-term longitudinal research design.

Following the deinstitutionalization of thousands of adults from state institutions in the United States beginning in the 1960s, nursing homes became a common source of residential care for persons with mental retardation. Yet, the use of nursing homes as an alternative source of care came into question as early as the 1970s. Many residents living in nursing homes did not have health problems that required 24-hour nursing care. In addition, nursing homes do not typically provide the type of habilitative services that people with mental retardation require (Lakin, Hill, & Anderson, 1991). Advocacy efforts on the part of policymakers, practitioners, families, and their relatives with mental retardation helped bring about the passage of the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) by Congress. This act contained the Nursing Home Reform Amendments, which required that persons with mental retardation who do not need skilled nursing care be transferred out of nursing homes to alternative community residential settings. (Persons living in nursing homes for 20 months or longer could choose to stay.) Since the passage of OBRA '87, approximately one third of the estimated 51,000 persons with mental retardation living in nursing homes moved to community-based residential settings (Braddock, Hemp, Parish, & Rizzolo, 2000).

Several researchers have studied whether there are actual benefits to living in community settings as compared to nursing homes for persons with mental retardation. In a study of persons with cerebral palsy, Wilson, Huffman, and Conroy (1991) found that the individuals transferred out of nursing homes to smaller community settings had improved adaptive behavior (e.g., personal and living skills) as compared to those who remained. Heller, Factor, Hahn, and Hsieh (1998) reported that persons with mental retardation who moved out of nursing homes to community settings experienced improved health and increased levels of adaptive behavior. Those who remained experienced no improvement or deterioration. Yet, Wilson et al. (1991) and Heller, Factor et al. (1998) did not examine whether any specific characteristics of the environment beyond type of residence contributed to the differences in outcomes among residents who moved versus those who remained in nursing homes.

Other researchers have also explored the impact of the environment on well-being among persons with mental retardation. Most of these researchers examined the size and type of residential facilities as the primary predictors of resident outcomes, such as adaptive and maladaptive behavior, community integration, amount of choice made by residents, family satisfaction, health, and mobility (Conroy, 1996; Emerson et al., 2000; Hill, Rotegaard, & Bruininks, 1984; Stancliffe, 1997; Stancliffe & Abery, 1997; Stancliffe, Abery, & Smith, 2000). Overall, results of these studies indicated that better outcomes occur among persons with mental retardation living in (a) community settings as compared to institutions and nursing homes and (b) smaller versus larger facilities. It is important to acknowledge, however, that there are some studies in which investigators have found more negative outcomes (e.g., higher mortality rates) among persons living in California who moved from institutional settings to smaller, community settings (Strauss & Kastner, 1996; Strauss, Kastner, & Shavelle, 1998). Yet, research also conducted in California by O'Brien and Zaharia (1998) indicated a declining trend of mortality for persons living in community settings but not in institutions.

Generally, in the studies that were focused on size and type of facility, researchers did not address more specific aspects of the environment that influence outcomes among persons with mental retardation. Yet, some investigators have indicated that there are specific characteristics of the environment that are related to the size of the residence. For example, Stancliffe (1997) found that in smaller facilities there were more opportunities for residents to make choices. In addition, researchers have noted that smaller, community-based facilities are more likely to have policies and practices that support individual choice-making, involve residents in policymaking, have more home-like atmospheres, and promote greater family involvement in residents' lives (Conroy, 1996; Emerson et al., 2000; Stancliffe, 1997; Wehmeyer & Bolding, 1999).

Several researchers have looked more closely at specific aspects of the environment other than size and type of facility. Based on the premise that greater resident autonomy will improve the level of independence, community integration, and quality of life of persons with disabilities (Wehmeyer, Kelchner, & Richards, 1996; Wehmeyer & Metzler, 1995), a small number of studies were focused on the impact of choice-making and autonomy in residential settings on persons with mental retardation. People with disabilities living in residential settings that offer more opportunities to make choices exhibit more autonomous behavior (Wehmeyer & Bolding, 1999). Heller, Miller, and Hsieh (1998) examined the impact of greater autonomy provided to residents with mental retardation on their adaptive behavior, community integration, and health. In this investigation, the authors longitudinally studied 249 adults with mental retardation who had all lived in nursing homes at their baseline assessment. Three years after baseline, 50 of the adults had moved to community-based settings, and 199 remained in nursing homes. The authors found that greater opportunities to be involved in decision-making were associated with greater adaptive behavior and community integration. Heller, Miller, and Factor (1999), in a study involving 58 adults with mental retardation who had moved from nursing homes into community settings, found higher levels of adaptive behavior and community integration over a 3-year period if the residents were given greater opportunity to exert autonomy in their daily lives. Based on the results of earlier research, in the current investigation we focused on the presence of opportunities to exert autonomy as an important environmental characteristic that may be related to residential outcomes. We hypothesized that greater opportunities for residents to make choices in their respective residential settings would be associated with better resident well-being.

Researchers have not given much attention to how the quality of residents' physical environment may influence their well-being. In several previous studies, researchers noted that facilities with more attractive physical environments and more home-like atmospheres positively influenced adaptive behavior. Heller, Miller, and Hsieh (1998) examined the degree of variety and stimulation present in the residential environment that they defined as the degree of personalization, distinctiveness, and stimulation. They found that adults with mental retardation living in environments with greater variety and stimulation had higher levels of adaptive behavior. Eyman, Demaine, and Lei (1979) indicated that features of the physical environment, such as comfort, openness, and functionality, were related to positive adaptive behavior among persons with mental retardation. King and Raynes (1968) found that improvements in adaptive behavior were associated with environments that were individualized and stimulating. Thompson, Robinson, Farris, and Sinclair (1996) reported that persons with mental retardation living in environments identified as having “home-like” physical features were more likely to be involved in independent household chores than were those living in “institutional” environments. Positive physical qualities of housing environments for older residents have also been associated with enhanced resident functioning, activity level, and social contacts (Lawton, 1977; Moos & Lemke, 1980). We hypothesized that living in a more attractive, home-like physical environment would be associated with improvements in resident well-being over time.

Family relationships have an important influence on the social and psychological well-being of persons with mental retardation who live at home (Krauss, Seltzer, & Goodman, 1992; Hauser-Cram et al., 1999) as well as those who live outside the home (Seltzer, Krauss, Hong, & Orsmond, 1999). In addition, family involvement has been identified as a significant predictor of successful community adjustment among persons with mental retardation making transitions from institutional to community settings (Schalock, Harper, & Gening, 1981; Schalock & Lilley, 1986). Hill, Rotegard, and Bruininks (1984) found that greater family involvement played a significant role in increasing the social integration of persons with mental retardation. Furthermore, Blacher (1998) suggested that family involvement can have a positive influence on the health of persons with mental retardation living outside the family home. In the present study, we hypothesized that greater family involvement would be associated with improved well-being among persons with mental retardation.

As discussed above, some researchers have found that the environment of residential settings itself can influence the well-being of persons with mental retardation. Yet, this influence has only been studied over a relatively short period of time. It is possible that improvements in adaptive behavior and community integration could be the result of temporary effects of relocation (Heller, 1984). Research is needed to examine the impact of the environment on well-being over a longer time period. In the present study, we explored the long-term impact (8 years) of environmental characteristics on the adaptive behavior, community integration, and health of adults with mental retardation. Because we were studying a longer time period, we believed that it was also important to examine health as an outcome variable because as adults experience age-related changes, health problems may increase (Janicki & Breitenbach, 2000).

Because we examined outcomes over an 8-year period, we controlled for initial resident functioning. Differences in functioning at baseline may be associated with whether individuals moved to community settings or remained in nursing homes. Heller, Factor et al. (1998) found that residents who moved to community settings from nursing homes had higher adaptive functioning and were younger than those who remained. Thus, we included measures of the level of mental retardation, age, adaptive behavior, and health as controls in our analyses. In our analysis of community integration, we also included a baseline measure of this variable as a control.

Our purpose in the current investigation was to identify specific characteristics of the environment above and beyond size and type of facility that contribute to the well-being of adults with mental retardation living in community residences and nursing homes. In this longitudinal study we examined residents' well-being over an 8-year period in which many of the residents transferred out of nursing homes into community settings. Thus, we were able to examine outcomes over time as they were related to the environment of community-based residential settings and nursing homes. Our major research question addressed the extent to which opportunities to exert autonomy, family involvement, and the attractiveness of the physical environment influence the adaptive behavior, community integration, and health of adults with mental retardation. Information on aspects of the environment that promote positive outcomes may be useful to residential programs, regardless of their size or type, to help improve the quality of life for their residents.

Method

Using a longitudinal research design, we examined the impact of several features of residential settings for adults with mental retardation on their level of community integration, adaptive behavior functioning, and health. We collected baseline data from 1989 to 1990 and follow-up data 8 years later.

Participants

Participants were 186 individuals with mental retardation who were living in nursing homes at the 1989 baseline assessment. In 1989, we initially recruited 331 residents with mental retardation living in 18 nursing homes in Chicago and its suburbs. This sample included all of the individuals over the age of 30 with mental retardation living in nursing homes in that area. We conducted baseline assessments on all residents. During the 8-year follow-up period, 63 residents died and 68 refused to participate; we were unable to locate 14. Thus, longitudinal data were available on 186 residents. At the 8-year follow-up, 133 of the 186 study participants (72%) had moved into the community settings for people with mental retardation.

At baseline, the average age of these adults was 47.02 years (range = 31 to 81). Fifty-one percent were female. Thirteen percent of the residents had mild mental retardation; 9%, moderate; 6%, either no mental retardation or unknown; and 72%, severe to profound mental retardation. Fifty-one percent also had cerebral palsy, and 43% had epilepsy. Eighty-one percent were European American and 19% were African American. At follow-up, 133 participants were living in 44 different community settings, ranging in size from 1 to 382 residents (M = 50, standard deviation [SD] = 119.51), and 53 participants remained in 25 different nursing homes, ranging in size from 91 to 417 residents (M = 224, SD = 99.81). We were able to gather environmental data from 38 community residences and 17 nursing homes (the staff of 6 community settings and 8 nursing homes refused consent to allow our research team to gather environmental data). Overall, 82% of the participants were living in 23 community residential sites with 8 or fewer residents; 2%, in community settings with 10 residents; 1%, in a community setting with 18 residents; and 15%, in three Intermediate Care Facilities for the Mental Retarded (ICFs/MR) facilities with more than 20 residents. The mean staff–resident ratio was 1.30 for the community settings and .64 for the nursing homes. Residents had lived in the various community residential settings an average of 49.8 months (range = 2 months to 7.5 years). Those residents who remained in nursing homes had lived there an average of 11 years (range = 7 months to 19 years).

Procedure

Research staff collected data by interviewing staff members of residential facilities; reviewing resident records, including the Inventory of Client and Agency Planning (ICAP) assessment (Bruininks, Hill, Weatherman, & Woodcock, 1986), and making observations of the environment of each facility. The ICAP data were based on information previously completed by residential staff as part of state requirements. The research staff included social workers, nurses, and graduate students in public health, nursing, psychology, and social work. All research staff members participated in 2-day training sessions conducted by the first author prior to data collection. They received a written manual detailing the data-collection procedures and participated in interview role plays. An advanced practice nurse on our staff collected all the data on health and reviewed them for any inconsistencies. In several cases, there were inconsistencies between medical records and staff reports. In those situations, the sources were reexamined, and if the inconsistencies remained, the data were scored as missing. Training for conducting the environmental assessments included going out to the site with another project staff member and conducting independent ratings. The project staff members were allowed to collect data only after they reached 90% agreement with each other on the items. Research staff visited each residence twice. Prior to collecting the environmental assessments, they observed each site. In the second visit, they conducted the environmental assessment by interviewing staff members and making observations of each residence.

Measures

Resident measures

Individual-level assessments included measures of each resident's adaptive behavior, mental retardation, and community integration. The level of adaptive functioning was assessed using the Broad Independence Score from the ICAP. This measure includes a 77-item scale of adaptive functioning that measures an individual's ability to perform daily activities in the areas of motor, social and communication, personal living, and community living skills. Each adaptive item is a statement of a task in one of the four domains (e.g., “Turns knob and opens a door,” “Washes, rinses, and dries hair,” “Uses the words ‘morning’ and ‘night’ correctly,” and “Reaches for a person whom he or she wants”). The respondent rates the participant on each task, using a scale from 0 (never or rarely) to 3 (does very well). The test–retest reliability of the adaptive behavior reported in the ICAP manual for adults with mental retardation (N = 159) was .94 (M = 444.60, SD = 46.84), ranging from .88 to .95 on each of the four adaptive behavior domains. An interrater-reliability in the study reported in the ICAP manual of the adaptive behavior measure was conducted with 61 adults who had mental retardation. The interrater-reliability coefficients were all in the high .80s and low .90s (.86 to .94), even after controlling for age, with a median coefficient of approximately .90. The alpha reliability of this scale in the current study is .95 at baseline and .98 at follow-up. The mean adaptive score in this study was 399.76 (SD = 49.37, range = 310 to 536) at Time 1 and 396.03 (SD = 51.94, range = 310 to 505) at Time 2.

We used the level of mental retardation recorded in each resident's ICAP as our measure of mental retardation (each resident is required to have a completed ICAP in his or her record that is annually updated by residential staff). Each was rated on a scale of 1 (no mental retardation) to 5 (profound mental retardation). We assessed community integration by using the Community Integration Scale (Heller & Factor, 1991). A score on this scale was the mean rating of the frequency of participating in 12 activities, including visiting family or friends outside of the residence and going to movies, shops, restaurants, and church. A score of 1 (none) to 4 (two or more times per week) was given for each activity. The alpha reliability of this scale was .81 at baseline and .83 at follow-up.

Physical health was measured with a modified version of the Physical Health scale of the mid-length Multi-Level Assessment Instrument (Lawton, Moss, Fulcomer, & Kleban, 1982). It included five of the seven items of the scale: (a) overall health status, as rated by a nursing home primary caregiver or staff supervisor/house manager in a community setting (1 = poor to 4 = excellent); (b) number of days hospitalized in the last year (1 = 21 days and above, 2 = 7 to 20 days, 3 = 1 to 6 days, 4 = 0 days); (c) number of doctor visits in the last year (1 = 3 and above, 2 = 1 to 2, 3 = 0), and (d) the presence of a heart condition (0 = yes, 1 = no) or circulation condition (0 = yes, 1 = no). Instead of the Multi-Level Assessment Instrument item that rated the extent of activity restrictions, we included the number of days that typical activities were restricted due to health problems (1 = 21 days and above, 2 = 7 to 20 days, 3 = 1 to 6 days, 4 = 0 days). The total physical health scores ranged from 0 to 17. Cronbach's reliability alpha values for baseline and the follow-up assessment were .66 and .60, respectively.

Environmental measures

Measures of the environment included the type of residence (community setting vs. nursing home), the size of residential facilities, physical attractiveness, choice-making opportunities, and family involvement. We assessed the size of each residential facility by determining the total number of residents. The physical attractiveness of a setting was assessed by using the 28-item Physical Attractiveness Scale of the Multiphasic Environmental Assessment Procedure Rating Scale (Moos & Lemke, 1984), which is used to assess cleanliness, conditions, and aesthetic appeal of a facility. The alpha of this scale is .94. Examples of issues covered in the items are attractiveness of the site buildings and cleanliness of walls and floors. Choice-making was assessed by the Choice Scale (Heller et al., 1999). The informant was asked how often the resident was allowed to choose; there are 12 items, such as what to eat, what to wear, what to do on a day off, what TV shows to watch. The score is a sum of these 12 items. Each response ranges from 1 (never) to 3 (whenever he/she wants). The alpha of this scale is .96. Family involvement is a measure of the frequency the resident visited with a family member in the last year. It is a 5-point-Likert scale, ranging from 1 (never) to 5 (monthly or more).

Results

We conducted t tests to determine whether the independent and outcome variables in the current study were significantly different for people who moved to community settings and those who remained in nursing homes. The only significant differences were in adaptive behavior at Time 1 and Time 2, size of facility, and the extent of choice-making. Persons who moved to community settings scored higher in adaptive behavior at Time 1 and Time 2. The nursing homes were larger and provided fewer opportunities for choice-making (see Table 1).

Table 1

 Characteristics of Participants and Residence by Mover Status (N = 186)

 Characteristics of Participants and Residence by Mover Status (N = 186)
 Characteristics of Participants and Residence by Mover Status (N = 186)

We examined whether several environmental aspects of the residential setting for adults with mental retardation influence their level of adaptive behavior, community integration, and health. We conducted three hierarchical regressions with follow-up measures of adaptive behavior, community integration, and health as the outcome variables. Studies have shown that individuals who remain in nursing homes may be more likely to have some certain personal characteristics, such as older age, poorer health, and lower levels of adaptive behavior (Heller, Factor et al., 1998). We thought it was important to control for personal characteristics. In each regression analysis, baseline assessments of age and level of mental retardation, adaptive behavior, and health were entered in the first block as controls. In the regression that had a follow-up measure of community integration as the dependent variable, community integration at baseline was also entered in the first block as a control. Type of residence was entered in the second block so that we could examine the impact of other environmental variables on outcomes while controlling for resident characteristics and type of facility. In each regression analysis, the third block included measures of the size of facility, physical attractiveness, choice-making, and family involvement. Furthermore, we tested the interaction of mover status with age, health, and adaptive behavior and the time persons with mental retardation lived in their current residence. None of these interactions were significant. Correlations of the independent and dependent variables are provided in Table 2.

Table 2  Correlation Among Measure Variables

Table 2  Correlation Among Measure Variables
Table 2  Correlation Among Measure Variables

Adaptive behavior at follow-up

The results of the hierarchical regression of adaptive behavior are presented in Table 3. The results showed that predictor variables accounted for 73% of the variance, F(10, 175) = 48.88, p < .001. The first block of personal characteristic variables accounted for 70% of the variance, and adaptive behavior at baseline was the only significant predictor among these variables, p < .001. The second block, type of facility where residents were living at follow-up, accounted for 1% of the variance, p < .05. Hence, persons who moved to community settings had significantly higher levels of adaptive behavior at follow-up than did those persons who remained in nursing homes. Finally, the third block of other environmental characteristics accounted for 2% of the variance, p < .01. A more attractive physical environment, p < .05, and greater opportunity for residents to make choices, p < .01, were associated with higher levels of adaptive behavior at follow-up. When the environmental block was added to the regression, facility type was no longer significant.

Table 3  Summary of Hierarchical Regression on Adaptive Behavior and Community Integration

Table 3  Summary of Hierarchical Regression on Adaptive Behavior and Community Integration
Table 3  Summary of Hierarchical Regression on Adaptive Behavior and Community Integration

Community integration at follow-up

The results of the hierarchical regression of community integration are also presented in Table 3. Forty percent of the variance can be explained by the full model, F(11, 174) = 10.73, p < .001. The first block of personal characteristic variables accounted for 24% of the variance, p < .001. Adaptive behavior at baseline was the only predictor variable in the first block that was significantly related to community integration at follow-up. The second block of facility type accounted for 4% of the variance, p < .01. Thus, residents who moved to community-based residences were more integrated in the community at follow-up than those residents who remained in nursing homes. The third block of other environmental characteristics accounted for 12% of the variance, p < .001. Specifically, greater opportunities to make choices and family involvement, were associated with higher levels of community integration. Again, facility type was no longer significant when the environmental block was added to the regression.

Health

The results of the hierarchical regression of health indicate that only age and health at baseline were significantly related to health at follow-up. These predictor variables accounted for 5% of the variance, p < .05. The second and third blocks were not significantly related to health at follow-up.

Discussion

The present study provides a long-term examination of the relationship between characteristics of the environment and the well-being of persons with mental retardation who lived in nursing homes when they were initially assessed. Eight years after the baseline assessment, these adults had either moved to community-based settings or remained in nursing homes. Overall, our results point to specific environment features of residential settings that can influence the long-term well-being of adults with mental retardation. These features include opportunities to make choices, the physical attractiveness of a setting, and the extent of family involvement. It is important to note that residents who moved to the community did not experience improvement in adaptive behavior from baseline levels. Rather, these levels remained essentially level. Yet, residents who remained in nursing homes experienced a slight decrease in adaptive behavior. In addition, residents who moved out of nursing homes had higher levels of community integration at follow-up. It is possible that being able to make choices helps persons with mental retardation develop and maintain skills associated with greater adaptive behavior and being integrated in the community. For example, being able to choose what you wear may help persons with mental retardation develop skills related to dressing oneself. Opportunities to choose one's social activities may encourage greater socialization in the community.

Residents who lived in more physically attractive settings evidenced higher adaptive behavior scores than did those who lived in less physically attractive settings. This finding is similar to results of studies in which researchers examined the impact of the physical design features on behavior of older persons (Linn, Gurel, & Linn, 1977; Moos & Lemke, 1980). An environment that is attractive, clean, and well-maintained may communicate to persons with mental retardation that they are viewed positively and as persons of dignity. Consequently, they may be more likely to act in positive ways associated with adaptive behavior.

Greater family involvement was related to increased community integration over time. Families are often the primary source for expanding social networks outside of the residence where persons with mental retardation live. Families may encourage their relatives to participate in the community and be an important source of socialization outside the domain of the residential setting. For example, families may accompany their relatives with mental retardation to various activities. Also, they may encourage staff members to promote the community integration of their relative and advocate for more community supports. Thus, when families are more involved in the lives of their relatives with mental retardation living outside the home, the relatives may be more likely to experience involvement in the community. It is important that administration and staff of residential facilities, whether they are in community-based settings or nursing homes, encourage families to be involved in residents' lives and that they involve families in decision-making, planning, and the daily lives of their relatives. Baker and Blacher (1993) and Stoneman and Crapps (1990) reported that when the staff of residential programs provides involvement opportunities to family members, family involvement increases. Because many of the adults living in residential facilities are aging, their parents may no longer be living or be capable of being involved in their relatives' lives. Thus, other family members, such as siblings and other extended family members, may need to be encouraged to become involved in the lives of their relatives with disabilities (Krauss, Seltzer, Gordon, & Friedman, 1996). Placing persons with mental retardation in residences that are in closer proximity to their family has also been noted to increase involvement (Baker, Blacher, & Pfeiffer, 1996). In the present study, our measure of family involvement is limited to frequency of family visits. In future studies of family involvement, investigators should use more comprehensive measures to examine variables such as the inclusion of families in decision-making and the proximity of families to their relatives with mental retardation.

The health of individuals with mental retardation in our study was not influenced by any of the environmental variables we examined. The initial level of health and age of the residents were the only variables related to health at follow-up in the present study. It is likely that health is affected by other variables that we did not address, such as the type of disabilities an individual has (e.g., persons with Down syndrome tend to have greater health declines at a younger age) and the health care and health-promoting activities and safety present in a residential setting.

As was the case in earlier studies, in the present study the type of residence was related to the resident outcomes of adaptive behavior and community integration. Residents who moved to community-based settings had higher levels of adaptive behavior and community integration than did those who remained in nursing homes. Our findings are notable in that the majority of the residents had severe and multiple disabilities, and the data were gathered over an 8-year period. Following the results of previous researchers (Conroy, 1996; Heller, Factor et al., 1998; Heller, Miller, & Hsieh, 1998), this study provides additional evidence that community settings are associated with better resident outcomes. Unlike past research (Heller, Factor et al., 1998; Heller, Miller, & Hsieh, 1998, Stancliffe, 1997), facility size was not associated with resident outcomes. Although the type of facility was related to resident outcomes, it was no longer significant when specific environmental features were included in the model. Hence, it was not size or type of facility per se but specific aspects of smaller, community-based residences (e.g., opportunity for autonomy and physical attractiveness) that are likely associated with well-being. Most previous research on size and type did not address these variables.

Two potential limitations of the present study need to be mentioned. First, there was no random assignment of individuals with developmental disabilities to residential facilities at follow-up. Instead, we used a quasi-experimental design in which residents were assessed where they naturally ended up living. Because individuals who were functioning at higher levels (e.g., had better health and less severe disabilities) may have more been likely to move out of nursing homes, it was important to statistically control the individual resident's level of functioning.

Second, there may have been differences in the information provided by staff members from residential facilities, who were from a variety of settings in which residents were likely functioning at different levels. For example, nursing home residents may have generally had lower levels of adaptive behavior than did residents in community settings. Thus, the staff of nursing homes may have had a different frame of reference about what constituted adaptive behavior. In addition, variations in staff familiarity with residents could have influenced the validity of the information they provided. In future research investigators should include behavioral observations of variables such as choice-making, adaptive behavior, and community integration in lieu of or in addition to staff reports.

The results of the present investigation indicate that the environments of community-based settings better promote the well-being of adults with mental retardation than do the environments of nursing homes. This finding, in tandem with the findings of other researchers (Conroy, 1996; Heller, Miller, & Hsieh, 1998; Stancliffe, 1997), leads us to recommend community-based settings for persons with mental retardation who do not require skilled nursing care. Even for those residents who do require skilled nursing care, they may be better served by having skilled nursing settings that offer more opportunities to make choices, that are more physically attractive, and that encourage family participation in residents' lives.

Note: Preparation of this article was supported in part by the Rehabilitation Research and Training Center on Aging with Developmental Disabilities, University of Illinois at Chicago, through the U.S. Department of Education, National Institute on Disability and Rehabilitation Research, Grant H133B980046. The opinions contained in this paper are those of the grantee and do not necessarily reflect those of the U.S. Department of Education.

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Author notes

Authors:Tamar Heller, PhD ( theller@uic.edu), Professor, Interim Head, Alison B. Miller, PhD, Psychologist, and Kelly Hsieh, PhD, Research Specialist, Department of Disability and Human Development, University of Illinois at Chicago, 1640 W. Roosevelt Rd., Chicago, IL 60608